| NPI | 1083771190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MI 4301078502) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: MI 4301078502) |
| 261QU0200X Clinic/Center, Urgent Care (Licence: MI 4301078502) | |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2013-03-15 |